1326178245 NPI number — MAMMOTH LAKES ORTHOPEDICS ASSOCIATES

Table of content: DARYA GUBAREV CLAYTON DMD, MS (NPI 1861182511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326178245 NPI number — MAMMOTH LAKES ORTHOPEDICS ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAMMOTH LAKES ORTHOPEDICS ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326178245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23600 TELO AVE
Provider Second Line Business Mailing Address:
SUITE #180
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90505-4035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-257-1500
Provider Business Mailing Address Fax Number:
310-257-1506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
452 OLD MAMMOTH ROAD
Provider Second Line Business Practice Location Address:
SUITE R
Provider Business Practice Location Address City Name:
MAMMOTH LAKES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93546-5021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-924-8688
Provider Business Practice Location Address Fax Number:
760-924-8688
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STRIPLIN
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
310-508-7638

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G075766 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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